1942525688 NPI number — TRINITY PAIN CENTER LLC

Table of content: (NPI 1942525688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942525688 NPI number — TRINITY PAIN CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRINITY PAIN CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942525688
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8146 CEREBELLUM WAY
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
TRINITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34655-1784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-264-8865
Provider Business Mailing Address Fax Number:
727-608-4479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8146 CEREBELLUM WAY
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
TRINITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34655-1784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-264-8865
Provider Business Practice Location Address Fax Number:
855-801-6125
Provider Enumeration Date:
04/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BUSH
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
727-264-8865

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  ME98246 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DD544A . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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